Consent Form

Please fill out the following form so that we may better assist you:

Name:

First Name*

Last Name*

Date of Birth:

Day

Month

Year

Address:

Mailing Address*

City*

Postal Code*

Contact Information:

E-mail

Phone*

Issue:

Issue you need help with:

Have you retained legal counsel?* YesNo

If yes, please provide the name of your Legal Counsel:

Name of your Legal Counsel

Signature

Signed on*

I hereby request that the office of Brian Saunderson, Member of Provincial Parliament for Simcoe-Grey, assist me with the issue stated above.

For this purpose I authorize the office of the Member of Provincial Parliament Brian Saunderson and/or his representative to consult the necessary provincial government departments or agencies on my behalf and for the provincial government department/agency to release any and all information in my file to the Member of Provincial Parliament and his staff. MPP Brian Saunderson and his representatives may use and share with government officials any and all personal information and documentation, including correspondence, which I have provided to him or his representatives to the extent necessary in their efforts to assist me.

I agree